Efficacy of plant extracts for metabolic dysfunction-associated steatotic liver disease: a network meta-analysis

Background Metabolic dysfunction-associated steatotic liver disease (MASLD) is a leading cause of chronic liver disease worldwide, affecting approximately 38% of the global population. This network meta-analysis systematically compared the effects of different plant extracts on liver biochemical and non-invasive histological outcomes in patients with MASLD. Methods This study was performed in accordance with the PRISMA guidelines and registered with PROSPERO (CRD420251229711). We systematically searched PubMed, Embase, Cochrane Library, and Web of Science up to November 12, 2025 for randomized controlled trials (RCTs) assessing plant extracts in adults with MASLD. Primary outcomes were alanine aminotransferase (ALT), aspartate aminotransferase (AST), controlled attenuation parameter (CAP), liver stiffness measurement (LSM), and hepatic steatosis percentage. Network meta-analyses were conducted using Stata 15.1 and R 4.2.1. Results In total, 32 RCTs were included, involving 2,053 patients and 28 types of plant extracts. For liver enzyme outcomes, a novel curcumin preparation (CP) exhibited the highest ranking probability for ALT reduction (SUCRA: 91.93%), whereas cinnamon (Cin) ranked highest for AST reduction (SUCRA: 88.48%). For non-invasive histological outcomes, purslane (Pur) showed the greatest ranking probability for reducing LSM (SUCRA: 94.16%), while fenugreek (Fen) demonstrated favorable ranking probabilities for both CAP reduction (SUCRA: 79.07%) and hepatic steatosis percentage reduction (SUCRA: 86.97%). The overall methodological quality of the included studies was generally acceptable, and funnel plot assessments revealed no substantial evidence of publication bias. Conclusion Compared with placebo, most plant extracts do not achieve statistically significant improvements in liver biochemical or non-invasive liver-related outcomes, leaving their overall clinical efficacy uncertain. Although CP, Cin, Fen, and Pur showed favorable probability rankings for specific endpoints based on SUCRA values, these findings should not be interpreted as evidence of clinically meaningful superiority. Given the limited evidence, considerable heterogeneity, and uncertainty in comparative estimates, the current data do not support the use of plant extracts as standalone therapies for MASLD outside the context of concomitant lifestyle modification. Adequately powered, standardized RCTs are warranted to clarify their therapeutic effects. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/view/CRD420251229711 ; Identifier: CRD420251229711.